Searching for HIV Harmony in SADC
Panashe is a twenty-six-year-old Zimbabwean women living with HIV. She works in a restaurant in the old mining town of Roodepoort on the west rand of Johannesburg.
She has known she is HIV positive since she was twenty when she got tested in Harare by an organisation called the New Start Centre, though it was several years before she needed anti-retroviral treatment, which she started in Harare.
However, in Zimbabwe due to the economic crisis she was without work and decided to come to South Africa as an asylum seeker. Trying to ensure she continued treatment in this new country was a challenging and disorienting affair.
Since 2007 antiretroviral treatment (ART) has been made freely available, including to asylum seekers and refugees, in South Africa. However, there are no regional treatment guidelines or referral systems for cross-border migrants on treatment. Panashe’s experience of changing regimens and finding a new health provider was fraught with anxiety.
Her treatment provider in Zimbabwe provided her with three months of treatment, but no referral letter.
“At first they asked for transfer letter from Zim. That time I didn’t have a transfer letter; I just came. I didn’t know they want something, so I asked the health service from Zimbabwe,” she told me. She eventually managed to get a faxed referral leter.
Ordinarily, treatment regimen change is made in cases where there is viral resistance to a particular regimen, or side effects are particularly severe. However, for those like Panashe a forced change in regimen was necessary as a result of migrating.
Although Panashe is healthy now, the side effects of changing treatment were strong.
“I started feeling dizzy, having a headache, vomiting. It’s not easy,” she says, “After two weeks my body started to get used to the medicine. I have a problem because I fell pregnant, but to go to clinic to get pregnant they give you another tablet [ie. Antiretrovirals for prevention of mother to child transmission]. It was not easy to get it. Since I am a foreigner, they say come tomorrow.”
Panashe was also not introduced to any support groups in South Africa and feels that foreign-nationals are not welcomed into, or given information, about these.
Migration and Cross-Border Treatment
In spite of progressive policies toward foreign nationals, xenophobia within public health systems is often report by migrants in Johannesburg.
As Francois Venter of the Wits Reproductive Health and HIV Institute, based in Hillbrow, explained cross-border migrants “often don’t know how to negotiate foreign systems, don’t have family friends, and have to deal with xenophobic clinics.”
Venter noted that while in the last few years treatment regimens in the region are very similar, regimen changes can like those Panashe had to go through can produce “a slight change in side effects.”
However, even while regimen changes are possible, they can still be daunting for people living with HIV on treatment, and information about how to go about moving treatment sites across borders is scarce. Often providing additional pills in case of mobility is left to the discretion of doctors, and little information is provided about how to go about transfers.
I met Lois Chingandu, the director of Southern Africa HIV and AIDS Information Dissemination Service (SAfAIDS) in the leafy Harare suburb of Avondale in April this year. SAfAIDS in a regional organization that was founded in 1994.
In spite of the economic and political challenges Zimbabwe has faced over the past two decades, Zimbabwe has a relatively well functioning and and expansive ART programme and a number of civil society organisations like SAFAIDS involved in HIV/AIDS work.
According to Chingandu, today over 1500 sites in Zim offering treatment antiretroviral treatment and prevention of mother to child transmission.
“Treatment is widely available,” she said, “But we still have challenges with people that presenting late.”
According to UNAIDS Zimbabwe reports an estimated ART coverage of 62% of those eligible for treatment compared to South Africa’s 48%.
Chingandu said that the is a problem with a lag between testing, diagnostics and treatment. While treatment is free sometimes patients are required to pay for diagnostics like liver function tests
Chingandu also raised the concern around the lack of an effective coordinated regional response in dealing with migration in the region:
‘We have a dual migration issue in that we have our own people from Zimbabwe going to South Africa and we have Zimbabweans people from South Africa returning home. If you are coming from South Africa, you maybe are on a different regiment from the one available in Zimbabwe because the two countries have not harmonized drugs regiments and management models”
SAfAIDS has been advocating for Southern African Development Community (SADC) countries to harmonize treatment protocols and improve cross-border referrals. This lack of a regional approach has also affected donor-based funding and programmes.
I also spoke to Mark Troger the country head of the United States funded President’s Emergency Plan For AIDS Relief (PEPFAR). PEPFAR invests “about $135m per year” per year in Zimbabwe and a large percentage goes to commodities, and purchasing medication, along with support for education and prevention programmes.
Troger was relatively positive about treatment roll-out in Zimbabwe, citing retention rates of 85%, although also expressing concern about a lag between testing and treatment. He acknowledged though that PEPFAR funded programmes tend to focus on countries, rather than at regional levels, and that cross-border migration had not been a high priority, though there is programme providing HIV services around the border town of Beitbridge.
The Move Towards Regional Harmonisation
Moeketsi Modisenyane is the Director for African and Middle East Relations in the South African Department of Health and a PhD Candidate at the University of Pretoria. He has been involved in regional policy discussions over the past decade.
According to Modisenyane there has been a significant movement towards regional harmonisation over the past decade, though challenges remained.
For instance the 2009 Policy Framework for Population Mobility and Communicable Diseases in the SADC Region calls for a “Coordinated cross-border referral services and mechanisms for continuity of care for patients with communicable diseases, particularly diseases requiring prolonged treatment such as TB (especially drug resistant TB) and HIV.”
“Some of the major challenges are the treatment protocols and guidelines, different countries still seem to have different protocols on HIV, TB, Malaria,” says Modisenyane, “First, it’s the drugs used, some of the countries are moving towards common drugs prescribed by WHO, others take time from drugs used to new ones as they have to get funding to move towards new drugs.”
However, he noted that there a major issue is that there is still not a regional policy framework for the referrals, and to deal with mobility, leaving this to the discretion of clinics and clinicians.
“There is still a problem. In fact, most of the health professionals at a facility utilize their own innovations in ensuring that referrals,” he says, highlighting that, at present, the Department of Health is presently working on developing a new internal referral policy which will also address cross-border referrals.
These could ensure that patients don’t miss treatment when travelling or migration – which poses both individual and public health risks due to the potential spread of drug resistance – but also to ensure that migrants can return home knowing they can continue treatment.
Panashe would like if economic conditions improve to return to Zimbabwe. However, she fears going through the process of having to change her treatment again, and lacks information on how she would transfer her treatment back to Zimbabwe.
Panashe’s story, and the accounts above, show that with the regional expansion of ART, much still needs to be done in integrating a migration perspective into programmes. This requires not only the regional harmonisation of treatment regimens and protocols, but also the development of regional referral systems, providing information about the possibilities for HIV treatment across borders at a clinic level, and the inclusion of foreign nationals into local support groups.
The Migration and Health Project Southern Africa is continuing to explore these issues through both regional policy dialogues and the experiences of those whose lives they shape.
Photograph by Matthew Wilhelm-Solomon from the border town of Musina.
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